Aim
The Primary and Community Health Services (PCHS) theme is grounded in a commitment to advancing health equity by tackling inequalities through focused engagement with the wider determinants of health.
Fundamental to this commitment is the development and continual refinement of more integrated ways of working, supported by a robust infrastructure that effectively connects users and providers of primary and community health services.
Principles of person-centred care concerning respect, dignity, compassion and personalisation, aligned with efforts to prioritise the needs, values and preferences of individuals, combine to guide our commitment to all in the community.
Adopting systems thinking throughout, the PCHS theme is similarly committed to strengthening the health and wellbeing of the workforce, within the context of supporting the overall recovery and growth of the health and care systems.
Meet the Team
Primary and Community Health Services Theme Lead
Implementation Manager, Primary and Community Health Services
Research Fellow Primary and Community Health Services
Projects
Tackling health inequalities
With our region home to some of the most deprived coastal communities, engaging directly with issues of health equity is a guiding priority. We work in partnership with marginalised and disadvantaged populations to tackle health inequalities, in this way aligning with the NHS England Core20Plus approach to engage with the target population. Actively listening to the voices and needs of people who are seldom heard, and collaboratively developing interventions and services that empower and improve their lives is key to the portfolio of work supported and produced by the theme.
Related projects:
Sussex Friendship Bench
The Friendship Bench is an internationally successful community-based mental health intervention that originated in Zimbabwe, founded by Dixon Chibanda in 2006. Central to the Friendship Bench initiative is the training of community (lay) health workers to provide one-to-one problem-solving based talking therapy from a bench located in a safe space within the community it hopes to support. Guided by our overarching goal to tackle health inequalities, we are bringing this initiative to Sussex, as an intervention to support and empower refugees and asylum seekers, as research robustly indicates that migrants typically experience higher rates of mental illness and poorer wellbeing compared to non-migrants. This community-based approach responds to shortfalls in mental health primary care resources by building capacity and capability within communities. To deliver the feasibility study we are collaborating with Diversity Resource International, a local non-profit social enterprise with expertise in supporting ethnically diverse and migrant communities in Sussex.
Alternative ways of working: digital innovations and place-based interventions
With a forward-looking focus on innovation, we are exploring alternative ways of working incorporating digital advancements and place-based interventions to enhance healthcare accessibility. Trialling resourceful ways to respond to ever increasing demand has the potential to make healthcare more widely and rapidly available. By refining services and related resources, we aim to improve operational efficiency and ensure the delivery of cost-effective, sustainable care and treatment.
Related projects:
interRAI Self-reported Assessment for Mental Health (SAMH) UK pilot
We are collaborating with the University of Waterloo, Canada, to provide the UK arm of a multi-national trial of the interRAI Self-reported Assessment for Mental Health (interRAI SAMH). The interRAI SAMH is a self-reported assessment questionnaire designed to determine the mental health and physical wellbeing of community-dwelling adults. The UK pilot is investigating the feasibility, acceptability, and cultural appropriateness of the interRAI SAMH for use by a community-based population of adults with mental health needs, with the option of completing the assessment with the assistance of a self-nominated supportive other. This assessment questionnaire is designed to facilitate the early identification of needs, thereby potentially providing support to prevent the progression of mental and physical health conditions.
Co-production
Echoing broader NIHR directives, the theme subscribes to the premise that the views of those with experience of and directly impacted by health issues should be meaningfully considered within related research, both as a matter of principle and with potential productivity and related impact in mind. Broad systemic inequalities permeate the research environment, often resulting in a lack of appropriately diverse representation within projects focused on redressing health inequalities. We endeavour to consistently collaborate with communities, holding up principles and practices of equality and inclusion throughout each phase of the research process. Our aim is to gain a deep understanding of community needs through active engagement, thereby promoting the development of interventions designed to effectively and sustainably serve those they will support, while endorsing practices of empowerment.
Related projects:
Sussex Friendship Bench
The Friendship Bench is an internationally successful community-based mental health intervention that originated in Zimbabwe, founded by Dixon Chibanda in 2006. Central to the Friendship Bench initiative is the training of community (lay) health workers to provide one-to-one problem-solving based talking therapy from a bench located in a safe space within the community it hopes to support. Guided by our overarching goal to tackle health inequalities, we are bringing this initiative to Sussex, as an intervention to support and empower refugees and asylum seekers, as research robustly indicates that migrants typically experience higher rates of mental illness and poorer wellbeing compared to non-migrants. This community-based approach responds to shortfalls in mental health primary care resources by building capacity and capability within communities. To deliver the feasibility study we are collaborating with Diversity Resource International, a local non-profit social enterprise with expertise in supporting ethnically diverse and migrant communities in Sussex.
Sussex Friendship Bench Read:
A virtuous cycle of co-production: Reflection from a community priority-setting exercise.
Justlife, a charity advocating for those affected by hidden homelessness: How to set up a peer research group: a step-by-step manual | Justlife
Women’s health
Embracing an intersectional feminist approach that recognises the unique forms of multiple disadvantage and discrimination experienced by women with certain composite identities, the theme is committed to advancing research focused on improving the health outcomes of the hardest to reach women and girls. Aligning with the Women’s Health Strategy for England (2022), our stance takes on a life course angle, defined by a person-centred approach designed to meet the developing health needs of individuals, rather than focusing on specific conditions in isolation. Within this life course framework, the sexual health and sexual wellbeing of midlife women represents a priority interest under development in collaboration with academic partners at Brighton and Sussex Medical School, with particular attention focused on the most disadvantaged women within our region.
With partners at Brighton and Sussex Medical School and the Health Innovation Kent, Surrey and Sussex, we convene an active Women’s Health Research Network. This expanding network of academics, clinicians, commissioners and VCSEs meet regularly to discuss how best to build on existing research to further build related capacity and capability.
Related report:
Long-term conditions
Recognising the relevance of intersecting health inequalities to the prevalence of multiple long-term conditions experienced among the most disadvantaged, we aim to respond by developing integrated care across settings to support people to live well and for longer with chronic conditions. Examples of some chronic conditions include cardiovascular disease, mental health, chronic pain, cancer, Long COVID and physically persistent conditions.
Related projects:
SPICES-Sussex
This study aimed to co-produce and implement a community-based cardiovascular disease (CVD) risk assessment and reduction intervention to support under-served populations at moderate risk of CVD. The objectives were to enhance stakeholder engagement, to implement the intervention in four research sites, and to evaluate the use of Voluntary and Community and Social Enterprises (VCSE) and Community Health Worker (CHW) partnerships in health interventions.
The intervention showed significant improvements in CVD risk behaviours and received positive feedback for its holistic, personalised approach. Half of the VCSEs invited joined the program, and CHWs felt supported and empowered to deliver effective coaching. Co-design meetings allowed local adaptations, with 63% of participants completing the programme.
Healthy Hearts Sussex infographic
interRAI Self-reported Assessment for Mental Health (SAMH) UK pilot
We are collaborating with the University of Waterloo, Canada, to provide the UK arm of a multi-national trial of the interRAI Self-reported Assessment for Mental Health (interRAI SAMH). The interRAI SAMH is a self-reported assessment questionnaire designed to determine the mental health and physical wellbeing of community-dwelling adults. The UK pilot is investigating the feasibility, acceptability, and cultural appropriateness of the interRAI SAMH for use by a community-based population of adults with mental health needs, with the option of completing the assessment with the assistance of a self-nominated supportive other. This assessment questionnaire is designed to facilitate the early identification of needs, thereby potentially providing support to prevent the progression of mental and physical health conditions.
Using realist methodology in real-world research
Primary and community settings present complex challenges to the design, delivery and sustainability of effective services, with multiple unobservable social and structural processes at play. These dynamic contextual factors have important implications for intervention innovation and related service user engagement. Increasingly, we look to adopt realist methods capable of adequately capturing ‘how’, ‘why’, ‘when’, ‘for whom’ and ‘in what circumstances’ particular interventions are effective. A realist approach embraces our commitment to holistic, patient-centred care that carefully considers the particular circumstances of different services users.
Related resource: REALIST REVIEWS IN HEALTH POLICY AND SYSTEMS RESEARCH - Evidence Synthesis for Health Policy and Systems: A Methods Guide - NCBI Bookshelf
Our work with the Research Engagement Network (REN) in Sussex
In 2022, NHS England and the Department of Health and Social Care launched the Research Engagement Network (REN) Development Programme to enhance diversity in health research participation. This initiative funds Integrated Care Systems (ICS) to collaborate with local VCSE organisations, aiming to engage underrepresented communities and foster lasting, trust-based relationships for inclusive research.
Two grant award applications were recently successful.
- Mental health needs of women in deprived and coastal areas.
This project addresses the urgent mental health needs of women in deprived, coastal communities in Sussex through a collaborative effort with NHS Sussex, public health teams, and the Sussex Health Research Partnership. Focusing on women and intersectionality, it includes co-developed, interactive training on collaborative community research and tailored ethics training. Community researchers will lead participatory projects to engage marginalised groups, such as homeless, neurodivergent, older (50+) isolated, non-English speaking, and Trans, Non-Binary & Intersex groups (TNBI) individuals. Aligned with ARC KSS PCHS focal areas, this initiative emphasises active inclusion of disadvantaged groups, with the ARC KSS being instrumental in facilitating partnerships between community researchers and mentors to support effective project planning and delivery.
- Embedding community research to tackle health inequalities.
The second phase of the pan-Sussex Diversity in REN aims to embed community research into the health and care research cycle to address health inequalities. A key focus is on cancer, with a new partnership formed between the Sussex Cancer Research Centre and community researchers to create a diverse, inclusive engagement strategy. This initiative, aligning with ARC KSS PCHS focal areas of tackling health inequalities and prioritising long-term conditions, will include a Continued Professional Development programme to support community researchers and organisations, setting a model for best practices in diverse research engagement.
Upcoming projects
Autistic Adults’ Mental Health
In response to regional calls to prioritise the health and care needs of autistic and neurodivergent people, we are preparing to begin a NIHR Future Leaders Award-funded project focused on improving the accessibility and acceptability of mental health service provision for autistic adults, including suicide awareness and prevention strategy development.
Autistic adults report higher levels of unmet mental health needs compared non-autistic adults. Moreover, research reports higher rates of self-harm and suicidality among autistic adults, with autistic adults over 11 times more likely to die through suicide. Findings illustrating autistic adults disproportionate experience of challenges to accessing and engaging in mental health services indicates the stark mismatch between their mental health needs and the availability of accessible and acceptable relevant support. Social communication challenges, sensory sensitivities, and discomfort with unfamiliar settings and uncertainty represent key barriers to autistic adults’ willingness to access support, however these challenges are further complicated by the stigma often associated with Autistic Spectrum Condition.
The project will begin by establishing an Autistic Adults Mental Health Alliance for Kent, Surrey and Sussex early in 2025, with the experienced contributions of this collaborative working group being integral to the development and delivery of the project.
Previous projects
SPICES-Sussex
This study aimed to co-produce and implement a community-based cardiovascular disease (CVD) risk assessment and reduction intervention to support under-served populations at moderate risk of CVD. The objectives were to enhance stakeholder engagement, to implement the intervention in four research sites, and to evaluate the use of Voluntary and Community and Social Enterprises (VCSE) and Community Health Worker (CHW) partnerships in health interventions.
The intervention showed significant improvements in CVD risk behaviours and received positive feedback for its holistic, personalised approach. Half of the VCSEs invited joined the program, and CHWs felt supported and empowered to deliver effective coaching. Co-design meetings allowed local adaptations, with 63% of participants completing the programme.
Healthy Hearts Sussex infographic
Perinatal Obsessive-Compulsive Disorder and psychological treatment access
The perinatal period can make parents vulnerable to experiencing mental health problems. However, perinatal obsessive-compulsive disorder (PNOCD) is under-recognised and under-diagnosed, despite effective treatments being know. This study aimed to understand the experiences of those who have and haven't used services in order to increase access. It used seven semi-structured interviews conducted by the PI and one expert-by-experience (EBE). EBEs were involved through the project. From the interviews and previous literature, seven barriers with 43 sub-barriers were presented to healthcare professionals for them to prioritise in order of importance.
View an infographic: What do patients see as helping and hindering them from getting to therapy via primary care for depression and anxiety?
Growing Health Together
This initiative empowers clinicians to collaborate with local communities, designing evidence-based solutions to improve health and meet specific needs. Surrey Heartlands ICS invited Growing Health Together (GHT) to work with groups of Primary Care Networks (PCN) in East Surrey, fostering partnerships with community members and local organisations. Led by Dr. Gillian Orrow and colleagues Katherine Saunders and Dr. Michael Bosch, GHT began in one PCN and now spans five across Surrey.
ARC KSS was integral to this project, initiating early discussions through an ARC funding call focused on care. We supported GHT in securing evaluation funding, ensuring a strong focus on implementation and audience from the beginning. The team mapped the GHT ecosystem to understand the stakeholders, their roles, and relationships. This evaluation will identify the “active ingredients” that make GHT effective and adaptable. With successful evaluation, GHT’s approach could serve as a model for primary care, offering holistic benefits for individuals, communities, and the healthcare workforce.
Virtual consultations for people with learning disabilities
This study co-designed best practice guidance and resources to improve virtual consultations for people with learning disabilities and involved input from individuals with learning disabilities, their families, and healthcare professionals. It aimed to assist healthcare professionals, enhance digital inclusion, improve access, and ensure better-integrated care for people with learning disabilities and their families.
The study followed three stages:
Stage 1 – Conducted a rapid review of existing guidance, observed virtual consultations, and held qualitative interviews.
Stage 2 – Created a narrative film to highlight key touchpoints, which was then presented at priority-setting events and a collaborative co-design workshop.
Stage 3 – Developed supportive materials, including guidance and training resources for healthcare professionals and accessible information for people with learning disabilities and their families.
